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Agitation in dementia: Are drugs the best treatment?

A common symptom among people with dementia is agitation, which can affect their and their carers' well-being. Dementia experts conducted a new study and found the most effective means of addressing agitation.

A newly published paper outlines the best approaches for dealing with dementia-driven agitation and psychosis.

In a paper that is now published in the journal International Psychogeriatrics, experts from several research institutions — including the University of Michigan in Ann Arbor, and Johns Hopkins University in Baltimore, MD — express their consensus on the best approaches to manage dementia-related behavioral and psychological symptoms.

This paper — which is based on evidence presented by dementia experts across the globe — ranks the best methods of addressing agitation in Alzheimer's, and nondrug-based approaches come first.

"This research advocates a significant shift from current practice, recommending that nonpharmacological treatments are a first-line approach for agitation in dementia."

Study co-author Dr. Helen Kales, University of Michigan

Person-centered care to be prioritized

In the new study, the first four treatments that the researchers advise healthcare professionals and other caregivers to prioritize are all nonpharmacological, focusing on behavioral approaches instead.

The specialists advise, first and foremost, the assessment and management of underlying causes for agitation and other behavioral and psychological symptoms.

They also encourage providing appropriate education to caregivers and adapting the environment that people with Alzheimer's inhabit to suit their needs as closely as possible.

According to the experts' evidence, a person-centered approach to care and providing an activity program that fits the individuals' needs are, more often than not, preferable to administering drugs when it comes to addressing agitation.

As for the pharmacological treatments, the highest-ranking drug for behavioral symptoms was the antidepressant citalopram, and even this only ranked sixth on the experts' list. Medication for pain management also ranked higher than other drugs.

Of the antipsychotic drugs currently prescribed, the specialists consensually recommended only risperidone, which came in seventh on the list of treatments and approaches.

"Aside from risperidone at number [seven] in the list, none of the other atypical antipsychotic drugs were recommended," notes Dr. Kales.

"This is a very welcome change," she emphasizes, "given the known harms associated with these treatments."

Only one antipsychotic is effective

When it comes specifically to managing psychosis — including hallucinations and delusions — in people with a form of dementia, the specialists strongly advise that healthcare professionals first thoroughly assess patients for underlying causes and aim to manage these.

Once more, the panel of experts only consensually approved the antipsychotic drug risperidone, and it came second on their list of appropriate treatments for symptoms of psychosis.

Risperidone, the researchers add, is the only antipsychotic whose effectiveness in the context of dementia is backed up by scientific evidence.

This approach requires identifying a person's triggers for agitation and other behavioral symptoms to prevent or address them more systematically.

One preferred strategy in the DICE approach is using music to manage mood, which has been shown to work in many cases of dementia, and which allows healthcare professionals to avoid prescribing drugs that may have harmful side effects.

"Symptoms such as psychosis and agitation can be particularly distressing and challenging for people with dementia, their carers, and their families," notes study co-author Prof. Clive Ballard, from the University of Exter Medical School in the United Kingdom.

"Many commonly prescribed medications can cause harm, in some cases significantly increasing risk of stroke or death," he explains.

However, he adds that "[we] now know that nondrug approaches are the best starting points and can prove effective," and [the current] research provides more specific and targeted guidance to support clinicians to give the best possible treatment options."

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